Associations of dietary patterns with bone density and fractures in adults: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Although nutrition is important to bone health, the impact of different dietary patterns on bone density and fracture is unclear. The aim of this study was to synthesise conflicting evidence from observational studies to determine associations of empirically derived dietary patterns with bone density and fracture in healthy adults.

METHOD

A systematic review (PROSPERO CRD42017071676) with meta-analysis where possible (for hip fracture) and otherwise with best-evidence synthesis.

RESULTS

Twenty-one studies were included in the best-evidence synthesis and four in the meta-analysis. Meta-analysis demonstrated a protective association between 'healthy' pattern score and hip fracture (risk ratio 0.73; 95% confidence interval: 0.56, 0.96; I2 = 95%) for highest compared to lowest 'healthy' pattern score category. In best-evidence synthesis, there was conflicting evidence for associations of both pattern scores with bone density at all sites and total fractures and for 'Western' score and hip fracture. No study reported detrimental effects of 'healthy' patterns, or beneficial effects of 'Western' patterns.

DISCUSSION

The results suggest that general practitioners promoting a 'healthy' dietary pattern is, at worst, unlikely to be detrimental for bone health and, at best, may reduce hip fracture.

Patellar tendon enthesis abnormalities and their association with knee pain and structural abnormalities in older adults

OBJECTIVE

To describe associations between presence of patellar tendon enthesis (PTE) abnormalities and symptoms, structural abnormalities, and total knee replacement (TKR) in older adult cohort.

METHODS

PTE abnormalities (presence of abnormal bone signal and/or bone erosion), were measured on T2-weighted magnetic resonance (MR) images at baseline in 961 community-dwelling older adults. Knee pain and function limitation were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Bone marrow lesions (BMLs), cartilage volume and defects score, and infrapatellar fat pad (IPFP) area were measured using validated methods. Incidence of TKR was determined by data linkage.

RESULTS

Participants with abnormal PTE bone signal and/or erosion was 20%. Cross-sectionally, presence of PTE abnormalities was associated with greater pain intensity while going up and down stairs (β = 0.22 (95% confidence interval (CI); 0.03, 0.41)), greater risk of femoral BMLs (RR = 1.46 (1.12, 1.90)) and worse tibial cartilage defects score (RR = 1.70 (1.16, 2.47), and smaller IPFP area (β = -0.27 (-0.47, -0.06) cm²), after adjustment of confounders. Longitudinally, presence of baseline PTE abnormalities was associated with a deleterious increase in tibial BML size (RR = 1.52 (1.12, 2.05)) over 10.7 years but not symptoms, other structural changes, or TKR.

CONCLUSION

PTE abnormalities are common in older adults. Presence of cross-sectional but not longitudinal associations suggests they are commonly co-exist with other knee structural abnormalities but may not play a major role in symptom development or structural change, excepting tibial BMLs.

Associations of health literacy with diabetic foot outcomes: a systematic review and meta-analysis

BACKGROUND

People with diabetes have low health literacy, but the role of the latter in diabetic foot disease is unclear.

AIM

To determine, through a systematic review and meta-analysis, if health literacy is associated with diabetic foot disease, its risk factors, or foot care.

METHODS

We searched PubMed, EMBASE, CINAHL, Web of Science, Scopus and Science Direct. All studies were screened and data extracted by two independent reviewers. Studies in English with valid and reliable measures of health literacy and published tests of association were included. Data were extracted on the associations between the outcomes and health literacy. Meta-analyses were performed using random effects models.

RESULTS

Sixteen articles were included in the systematic review, with 11 in the meta-analysis. In people with inadequate health literacy, the odds of having diabetic foot disease were twice those in people with adequate health literacy, but this was not statistically significant [odds ratio 1.99 (95% CI 0.83, 4.78); two studies in 1278 participants]. There was no statistically significant difference in health literacy levels between people with and without peripheral neuropathy [standardized mean difference -0.14 (95% CI -0.47, 0.18); two studies in 399 participants]. There was no association between health literacy and foot care [correlation coefficient 0.01 (95% CI -0.07, 0.10); seven studies in 1033 participants].

CONCLUSIONS

There were insufficient data to exclude associations between health literacy and diabetic foot disease and its risk factors, but health literacy appears unlikely to have a role in foot care. The contribution of low health literacy to diabetic foot disease requires definitive assessment through robust longitudinal studies.

The association between ambulatory activity, body composition and hip or knee joint replacement due to osteoarthritis: a prospective cohort study

OBJECTIVE

To examine the association between ambulatory activity (AA), body composition measures and hip or knee joint replacement (JR) due to osteoarthritis.

DESIGN

At baseline, 1082 community-dwelling older-adults aged 50-80 years were studied. AA was measured objectively using pedometer and body composition by dual-energy X-ray absorptiometry. The incidence of primary (first-time) JR was determined by data linkage to the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Log binomial regression with generalized estimating equations were used to estimate the risk of JR associated with baseline AA and body composition measures, adjusting for age, sex, X-ray disease severity, and pain.

RESULTS

Over 13 years of follow-up, 74 (6.8%) participants had a knee replacement (KR) and 50 (4.7%) a hip replacement (HR). AA was associated with a higher risk of KR (RR 1.09/1000 steps/day, 95% CI 1.01, 1.16) and a lower risk of HR (RR 0.90/1000 steps/day, 95% CI 0.81, 0.99). Body mass index (BMI) (RR 1.07/kg/m², 95% CI 1.03, 1.12), total fat mass (RR 1.03/kg, 95% CI 1.01, 1.06), trunk fat mass (RR 1.05/kg, 95% CI 1.00, 1.09), and waist circumference (RR 1.02/cm, 95% CI 1.00, 1.04) were associated with a higher risk of KR. Body composition measures were not associated with HR.

CONCLUSIONS

An objective measure of AA was associated with a small increased risk of KR and a small reduced risk of HR. Worse body composition profiles were associated with KR, but not HR. Altogether this may suggest different causal pathways for each site with regard to habitual activity and obesity.

Cut-points for associations between vitamin D status and multiple musculoskeletal outcomes in middle-aged women

This was the first study examining optimal vitamin D status for musculoskeletal health in middle-aged women. A 25-hydroxyvitamin D level of at least 29 to 33 nmol/L appears required for optimal musculoskeletal health, but the current cut-off of 50 nmol/L may be warranted.

INTRODUCTION

This study aimed to determine whether cut-points exist for associations between serum 25-hydroxyvitamin D (25OHD) and musculoskeletal health outcomes in middle-aged women, below which greater 25OHD levels are associated with musculoskeletal health benefits and above which no such associations exist.

METHODS

This is a cross-sectional study of 344 women aged 36-57 years. Cut-points for associations of serum 25OHD with lumbar spine (LS) and femoral neck (FN) bone mineral density (BMD), lower limb muscle strength (LMS), timed up and go test (TUG), functional reach test (FRT), lateral reach test (LRT), and step test (ST) were explored using locally weighted regression smoothing and nonlinear least-squares estimation, and associations above and below the identified cut-points were estimated using segmented regression.

RESULTS

The prevalence of low 25OHD was 28 % (<50 nmol/L). Significant cut-points (nmol/L) were identified for FN BMD 31 (95 % confidence interval (CI): 18, 43), LS BMD 31 (17, 45), TUG 30 (24, 36), ST 33 (24, 31), FRT 31 (18, 43), and LMS 29 (8, 49) but not LRT (42 (-8, 93). Below these cut-points, there were beneficial associations between higher 25OHD level and each outcome, while above the cut-points, there were no beneficial associations.

CONCLUSIONS

In middle-aged women, there are thresholds for associations between serum 25OHD concentrations and bone density and most balance measures, suggesting that 25OHD levels of at least 29 to 33 nmol/L are required for optimal musculoskeletal health in this population. The current cut-off of 50 nmol/L may be higher than needed for some outcomes but appears warranted overall.

Prospective Associations of Low Muscle Mass and Function with 10-Year Falls Risk, Incident Fracture and Mortality in Community-Dwelling Older Adults

OBJECTIVES

Purpose: To compare the performance of low muscle mass and function with falls risk, incident fracture and mortality over 10 years.

METHODS

1041 participants (50% women; mean age 63±7.5 years) were prospectively followed for 10 years. Falls risk was measured using the Physiological Profile Assessment, fractures were self-reported and mortality was ascertained from the death registry. Appendicular lean mass (ALM) was assessed using dual energy X-ray absorptiometry. Four anthropometric: (ALM/height2, ALM/body mass index, ALM/weight×100, a residuals method of ALM on height and total body fat) and four performance-based measures: (handgrip strength, lower-limb muscle strength, upper and lower-limb muscle quality) were examined. Participants in the lowest 20% of the sex-specific distribution for each anthropometric and performance-based measure were classified has having low muscle mass or function. Regression analyses were used to estimate associations between each anthropometric and performance-based measure at baseline and 10-year falls risk, incident fractures and mortality.

RESULTS

Mean falls risk z-score at 10 years was 0.64 (SD 1.12), incident fractures and mortality over 10 years were 16% and 14% respectively. All baseline performance-based measures were significantly associated with higher falls risk score at 10 years. Low handgrip (RR 1.55, 95% CI: 1.09, 2.20) and ALM/body mass index (RR 1.54, 95% CI: 1.14, 2.08) were the only significant predictors of fracture and mortality respectively.

CONCLUSIONS

Low handgrip strength, a simple and inexpensive test could be considered in clinical settings for identifying future falls and fractures. ALM/ body mass index could be most suitable in estimating 10-year mortality risk, but requires specialised equipment.

Prospective outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease presenting to hospital: a generalisable clinical audit

BACKGROUND AND AIM

To determine predictors of short- and long-term outcomes in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) (AECOPD) presenting to hospital.

METHODS

A prospective clinical audit of AECOPD attendances to the only public acute general hospital in Southern Tasmania, Australia. Out of 416 attendances with AECOPD to the emergency department (ED) between November 2006 and July 2008, 150 patients with 218 attendances were followed to March 2009. Predictors of hospital admission from ED, in-hospital death, length of hospital stay, post-discharge mortality and re-attendance rate for AECOPD were the main outcomes.

RESULTS

There were no clear differences between patients admitted to hospital and those sent home from ED. Predictors of in-hospital death were initial physiologic parameters, that is, arterial pH, PaCO2 , oxygen saturation and blood pressure. Longer hospital stay was associated with older age, current smoking, hyperglycaemia, lower blood pressure and lower oxygen saturation. Risk of mortality after discharge was associated with a history of myocardial infarction, nursing home residence and severity of COPD. Re-attendance rate was associated with osteoporosis, younger age and severity of COPD.

CONCLUSIONS

Further investigation into the process of decision making about which AECOPD patients are admitted from the ED is required. Short-term outcomes, in-hospital death and length of hospital stay are mainly predicted by severity of the acute exacerbation and patient demographics. Although severity of COPD was a predictor of long-term outcomes, the main predictors of these were presence of co-morbidities.

Lower limb muscle strength is associated with poor balance in middle-aged women: linear and nonlinear analyses

This was the first study investigating both linear associations between lower limb muscle strength and balance in middle-aged women and the potential for thresholds for the associations. There was strong evidence that even in middle-aged women, poorer LMS was associated with reduced balance. However, no evidence was found for thresholds.

INTRODUCTION

Decline in balance begins in middle age, yet, the role of muscle strength in balance is rarely examined in this age group. We aimed to determine the association between lower limb muscle strength (LMS) and balance in middle-aged women and investigate whether cut-points of LMS exist that might identify women at risk of poorer balance.

METHODS

Cross-sectional analysis of 345 women aged 36-57 years was done. Associations between LMS and balance tests (timed up and go (TUG), step test (ST), functional reach test (FRT), and lateral reach test (LRT)) were assessed using linear regression. Nonlinear associations were explored using locally weighted regression smoothing (LOWESS) and potential cut-points identified using nonlinear least-squares estimation. Segmented regression was used to estimate associations above and below the identified cut-points.

RESULTS

Weaker LMS was associated with poorer performance on the TUG (β -0.008 (95 % CI: -0.010, -0.005) second/kg), ST (β 0.031 (0.011, 0.051) step/kg), FRT (β 0.071 (0.047, 0.096) cm/kg), and LRT (β 0.028 (0.011, 0.044) cm/kg), independent of confounders. Potential nonlinear associations were evident from LOWESS results; significant cut-points of LMS were identified for all balance tests (29-50 kg). However, excepting ST, cut-points did not persist after excluding potentially influential data points.

CONCLUSIONS

In middle-aged women, poorer LMS is associated with reduced balance. Therefore, improving muscle strength in middle-age may be a useful strategy to improve balance and reduce falls risk in later life. Middle-aged women with low muscle strength may be an effective target group for future randomized controlled trials.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) NCT00273260.

Evaluation of endostatin antiangiogenesis gene therapy in vitro and in vivo

Progressive growth and metastasis of solid tumors require angiogenesis, or the formation of new blood vessels. Endostatin is a 20-kDa carboxy-terminal fragment of collagen XVIII that has been shown to inhibit endothelial cell proliferation and tumor angiogenesis. Replication-deficient recombinant adenovirus (rAd) vectors were constructed, which encoded secreted forms of human and mouse endostatin (HECB and MECB, respectively), and, as a control, human alkaline phosphatase (APCB). Accumulation of endostatin was demonstrated in supernatants of cultured cells infected with the endostatin rAds. These supernatants disrupted tubule formation, inhibited migration and proliferation, and induced apoptosis in human dermal vascular endothelial cells or human vascular endothelial cells. Endostatin-containing supernatants had no effect on the proliferation of MidT2-1 mouse mammary tumor cells in vitro. A pharmacokinetic study of MECB in immunocompetent FVB mice demonstrated a 10-fold increase of serum endostatin concentrations 3 days after intravenous administration of 1x10(10) particles of this rAd (215-257 ng/mL compared to 12-38 ng/mL in control rAd-treated mice). Intravenous administration of MECB reduced b-FGF stimulated angiogenesis into Matrigel plugs by 38%. Intratumoral MECB inhibited growth of MidT2-1 syngeneic mammary tumors in FVB mice, but had minimal impact on the growth of MDA-MB-231 human breast tumors in SCID mice. Intravenous therapy with MECB also initially inhibited growth of MidT2-1 tumors, but this activity was subsequently blocked by induced anti-rAd antibodies. In summary, endostatin gene therapy effectively suppressed angiogenic processes in vitro and in vivo in several model systems.

Cyclin D-CDK subunit arrangement is dependent on the availability of competing INK4 and p21 class inhibitors

The D-type cyclins and their major kinase partners CDK4 and CDK6 regulate G0-G1-S progression by contributing to the phosphorylation and inactivation of the retinoblastoma gene product, pRB. Assembly of active cyclin D-CDK complexes in response to mitogenic signals is negatively regulated by INK4 family members. Here we show that although all four INK4 proteins associate with CDK4 and CDK6 in vitro, only p16(INK4a) can form stable, binary complexes with both CDK4 and CDK6 in proliferating cells. The other INK4 family members form stable complexes with CDK6 but associate only transiently with CDK4. Conversely, CDK4 stably associates with both p21(CIP1) and p27(KIP1) in cyclin-containing complexes, suggesting that CDK4 is in equilibrium between INK4 and p21(CIP1)- or p27(KIP1)-bound states. In agreement with this hypothesis, overexpression of p21(CIP1) in 293 cells, where CDK4 is bound to p16(INK4a), stimulates the formation of ternary cyclin D-CDK4-p21(CIP1) complexes. These data suggest that members of the p21 family of proteins promote the association of D-type cyclins with CDKs by counteracting the effects of INK4 molecules.

In vitro studies of the effect of antiseptic-containing mouthwashes on the formation and viability of Streptococcus sanguis biofilms

The aims of this study were to evaluate the growth of Streptococcus sanguis on hydroxyapatite, bovine enamel and polytetrafluoroethylene substrata in a constant depth film fermentor, and to determine the effects of three antimicrobial-containing mouthwashes on biofilm formation and bacterial viability on hydroxyapatite and enamel. There was little difference in the final cell density (5 x 10(4) cfu mm-2) of the Strep. sanguis biofilm on the three substrata. When hydroxyapatite-grown biofilms were exposed to the mouthwashes for 1 min, the one containing triclosan (T) proved the most effective. The chlorhexidine-containing mouthwash (CX) also achieved significant kills. The T-containing mouthwash was the most effective at killing biofilms grown on enamel. Pre-treatment of hydroxyapatite with CX, cetylpyridium chloride (CPC) or T for 1 min resulted in undetectable biofilm formation after 8 h. After 8 h of growth, only biofilms grown on enamel discs pre-treated with CX showed a reduction in the number of viable organisms. In conclusion, the results of this study have shown that while growth of Strep. sanguis on hydroxyapatite and enamel were similar, the ability of antimicrobial agents to prevent the accumulation of viable bacteria depended on the nature of the substratum.

Perceptions and experiences of occupational therapists in rural schools

Occupational therapy practice in rural schools is influenced by a number of factors unique to rural settings, such as geographic barriers, cultural diversity, limited access to external resources, and lack of personnel with specialist skills. The purpose of this ethnographic study was to identify the unique experiences of occupational therapists who practice in rural schools and to explore how they perceived their roles in rural schools. Six occupational therapists were interviewed and observed in the field. Analysis of interview data revealed five themes: (a) jack-of-all-trades, which described how the participants viewed themselves as generalists; (b) bridging the span between services, which described their roles in coordinating the students' medical services, which tended to be disjointed; (c) the world can get kind of lonely out there, which described the sources of support seen as reducing their sense of isolation; (d) trust and teaming, which described their attempts to provide an integrated intervention service and the challenges they faced; and (e) I cannot do it all, but I wish I could, which described how they selected their service delivery models to meet the demands of their practice. The participants believed that their work in rural schools required creativity, resourcefulness, and self-reliance. These characteristics, as well as support from their colleagues, were important to coping with the challenges of practice in rural schools.

p53 gene therapy in vivo of herpatocellular and liver metastatic colorectal cancer

Tumor suppressor genes such as p53 contribute to the oncogenic process via loss-of-function mechanisms such as genetic mutation or complex formation with other cellular or viral proteins. p53 is mutated in approximately 50% of human tumors and has an important role in the genesis or progression of both colorectal and hepatocellular cancers. Colorectal cancer is leading cause of cancer mortality in the United States, whereas hepatocellular cancer is the leading worldwide cause of cancer death; the liver is a primary site of morbidity in both diseases. Because systemic tumor suppressor gene therapy is currently not feasible, we have chosen to develop a regional form of such therapy directed at primary or metastatic liver neoplasms. Gene replacement therapy with p53 is a promising new strategy to treat advanced human cancers.

Psychosocial factors in childhood pedestrian injury: a matched case-control study. Kid's'n'Cars Team

HYPOTHESIS

Psychosocial factors--such as hyperactivity and low family cohesion--contribute to the risk for child pedestrian injury (PI), even after controlling for known demographic risk factors.

PARTICIPANTS

Urban PI victims aged 5 to 12 years were recruited from one large, urban pediatric trauma center in a large city. One hundred twenty-eight cases were matched to uninjured children on age, sex, race, location of residence, and parental education. Among matched cases: 70% were male, 41% were black, 33% were Hispanic, and 66% of the mothers had a high school education or less. RESEARCH DESIGN AND MEASUREMENTS: Case-control comparisons on 19 psychosocial variables drawn from interviews and standardized tests, using one-tailed matched-pairs t tests and conditional logistic regression analyses.

RESULTS

Cases had higher reported physical quotient [PQ] (P = .01), self-help quotient (P = .04), and family stress (P = .02), and lower family supportiveness (P = .03). Multivariate analyses confirmed that PQ was higher in cases (10-point increase: odds ratio (OR) = 1.32 [90% confidence interval (CI) 1.01-1.76], that stress was higher in cases (1 log increase: OR 2.13, [1.26-3.61]), and that cases had lower family supportiveness (25-point decrease: OR 1.43 [1.25-1.63]). It also identified household crowding as a factor for non-black cases (OR for increase of 0.25 people per room: 2.18, [1.31-3.62]).

CONCLUSION

Even when controlling for demographic risk, several family factors and one child factor place children at risk for PI. Clinicians may choose to use these as indicators for injury prevention counseling. Research on family effects may help clarify means to protect children who are demographically at risk for PI.

Thyroid hormone receptors repress estrogen receptor activation of a TRE

The identification of hormone response elements in the promoter regions of hormonally regulated genes has revealed a striking similarity between the estrogen response element (ERE) and a palindromic thyroid hormone response element (TRE) derived from the GH gene promoter. In addition, this TRE was described as a strong retinoic acid receptor response element for all three subtypes: alpha, beta, and gamma. We show here that the TRE in the absence of thyroid hormone receptor (TR) behaves similarly to imperfect EREs, which can synergize to mediate a strong estrogen-dependent activation of transcription. However, in the presence of TR, but the absence of T3, activation of the TRE constructs by estrogen receptor (ER) is inhibited. In vitro, ER and TR were found to bind to the TRE in the absence and presence of their respective ligands; however, TRs form a more stable complex with the TRE than does ER. To examine whether repression of ER activity on the TRE constructs by TR was due to heterodimer formation, we employed truncated TR mutants (tTR) that lacked the DNA-binding domain, but contained the ligand-binding/dimerization domain. The tTRs were shown to be efficient inhibitors of TR, but not of ER. Thus, inhibition of ER activity on TREs by TRs does not result from heterodimer formation. We discuss a mechanism in which TRs, in the absence of thyroid hormone, control TRE activation by related receptors by preventing their access to the TRE. This mechanism can greatly enhance the fidelity of the ligand-specific response from a TRE.

CT: to enhance or not to enhance: A computer-aided study

Statistical analysis was performed of the carefully coded results of computed tomographic scans, with and without contrast medium, of a substantial group of patients with proved diagnoses. Bayesian methods were used to provide computer-aided diagnoses with considerable success. Further analysis of these results suggested that expert advice can be provided by the computer concerning which patients would benefit diagnostically from enhancement after their plain scan description has been fed into the computer.

An improvement in computer-aided diagnosis of meningiomas after CT

CT examination of 497 patients with subsequently proven pathology have been analysed and subjected to computer-aided diagnosis using Bayes' theorem. Our previous work was as accurate and reliable for diagnosing metastases and gliomas as that achieved by skilled radiologists in reporting. The present paper reports an alteration to the programme that has improved the diagnosis of meningioma.

Initial findings in the computer-aided diagnosis of cerebral tumours using CT scan results

This paper describes the initial findings of computer-assisted diagnosis of cerebral tumours using Bayes' Theorem and CT scans. For various sets of signs, tables of accuracy and reliability have been constructed, and a computer versus radiologist analysis for three types of tumour has been made. Based only on the results of CT scans, the computer has produced diagnoses relatively quickly, and overall these are of reasonable accuracy when compared with the radiologists' reports. The worst results occurred in the prediction of meningiomas, the reasons for which will be examined in subsequent work.

Discussion on Mycosis Fungoides

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